Anxiety Disorders Back to Basics 2012 Dr. Holly Dornan PGY-4 Psychiatry Resident University of...

Anxiety DisordersAnxiety DisordersBack to Basics Back to Basics

20122012Dr. Holly DornanDr. Holly Dornan

PGY-4 Psychiatry ResidentPGY-4 Psychiatry Resident

University of OttawaUniversity of Ottawa

AnxietyAnxiety

LMCC ObjectivesLMCC ObjectivesKey ObjectivesKey Objectives In patients with many other medical complaints and/or In patients with many other medical complaints and/or

excessive utilisation of medical health care, determine excessive utilisation of medical health care, determine whether anxiety co-exists.whether anxiety co-exists.

Differentiate situational stress from true anxiety Differentiate situational stress from true anxiety disorder and from drug and physical causes of anxiety.disorder and from drug and physical causes of anxiety.

ObjectivesObjectives Through efficient, focused, data gathering:Through efficient, focused, data gathering: Review various physical symptoms briefly; elicit history Review various physical symptoms briefly; elicit history

of other non-psychiatric illness, intake of alcohol and of other non-psychiatric illness, intake of alcohol and caffeine, and a brief history of any major life stresses.caffeine, and a brief history of any major life stresses.

Elicit a history of excessive worry about events which Elicit a history of excessive worry about events which is out of proportion to the impact of the event; history is out of proportion to the impact of the event; history present for at least six months (anxiety).present for at least six months (anxiety).

LMCC ObjectivesLMCC Objectives Determine whether there is restlessness, fatigue, Determine whether there is restlessness, fatigue,

inability to concentrate, irritability, muscle tension, inability to concentrate, irritability, muscle tension, sleep disturbance.sleep disturbance.

Determine whether social, occupational, or function Determine whether social, occupational, or function in general has been affected.in general has been affected.

Determine whether co-morbid psychiatric disorders Determine whether co-morbid psychiatric disorders exist, stress, substance abuse, past sexual, physical exist, stress, substance abuse, past sexual, physical and emotional abuse, or neglect.and emotional abuse, or neglect.

Determine whether there is a discrete period of Determine whether there is a discrete period of intense fear, recurrent panic attacks,>1 month of intense fear, recurrent panic attacks,>1 month of concern about more attacks, change in behavior in concern about more attacks, change in behavior in relation to attacks, along with cardiopulmonary, relation to attacks, along with cardiopulmonary, neurologic, psychiatric or other medical symptoms ± neurologic, psychiatric or other medical symptoms ± agoraphobia.agoraphobia.

LMCC ObjectivesLMCC Objectives List and interpret critical clinical and laboratory List and interpret critical clinical and laboratory

findings which were key in the processes of findings which were key in the processes of exclusion, differentiation, and diagnosis.exclusion, differentiation, and diagnosis.

Conduct an effective initial plan of management for Conduct an effective initial plan of management for a patient with anxiety or panic:a patient with anxiety or panic:

Outline supportive therapy (e.g., psychosocial Outline supportive therapy (e.g., psychosocial interventions) and counseling and list indications interventions) and counseling and list indications for drug therapy (e.g., selective serotonin re-for drug therapy (e.g., selective serotonin re-uptake inhibitors).uptake inhibitors).

Select patients in need of specialized care.Select patients in need of specialized care.

LMCC ObjectivesLMCC Objectives

Applied Scientific ConceptsApplied Scientific Concepts

1. Explain that although the 1. Explain that although the pathophysiology of panic disorder/attacks pathophysiology of panic disorder/attacks is incompletely understood, the amygdala, is incompletely understood, the amygdala, locus ceruleus, and hippocampus along locus ceruleus, and hippocampus along with several neurotransmitters have been with several neurotransmitters have been the focus of attention.the focus of attention.

LMCC ObjectivesLMCC Objectives Causal ConditionsCausal Conditions 1. Panic attack1. Panic attack a. Cardiopulmonary symptoms - 40%a. Cardiopulmonary symptoms - 40% b. Neurologic symptoms - 40%b. Neurologic symptoms - 40% c. Gastrointestinal symptoms - 30%c. Gastrointestinal symptoms - 30% d. Psychiatric symptomsd. Psychiatric symptoms e. Autonomic symptomse. Autonomic symptoms

2. Panic disorder2. Panic disorder a. With agoraphobia/Without agoraphobiaa. With agoraphobia/Without agoraphobia b. With social/Specific phobiab. With social/Specific phobia c. Trauma/Stress related/Post traumatic stress disorderc. Trauma/Stress related/Post traumatic stress disorder

3. Associated with other conditions3. Associated with other conditions a. Depressiona. Depression b. Obsessive compulsive disorderb. Obsessive compulsive disorder c. Substance abusec. Substance abuse

4. Generalized anxiety disorder4. Generalized anxiety disorder

What is anxiety?What is anxiety? A feeling state consisting of physical, A feeling state consisting of physical,

emotional and behavioural responses to emotional and behavioural responses to perceived threatsperceived threats11

Diffuse, unpleasant sense of apprehension Diffuse, unpleasant sense of apprehension accompanied by physical symptoms such accompanied by physical symptoms such as headache, sweating, palpitations, chest as headache, sweating, palpitations, chest tightness, stomach upset, restlessnesstightness, stomach upset, restlessness

Normal and necessary part of everyday Normal and necessary part of everyday lifelife

1 Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006

Anxiety vs. FearAnxiety vs. FearAnxiety

Fear

Threat

Threat

Response to a threat that is unknown, internal, vague or

conflictual

Response to a known, external, definite threat

Anxiety as a DisorderAnxiety as a Disorder

When does anxiety become a disorder?When does anxiety become a disorder? 1)1) Greater intensity and/or duration than Greater intensity and/or duration than

expected given the circumstancesexpected given the circumstances

2)2) Leads to impairment or disability Leads to impairment or disability

3)3) Daily activities are disrupted by avoidance Daily activities are disrupted by avoidance of of certain situations or objects to decrease certain situations or objects to decrease

anxietyanxiety

4)4) Includes clinically significant unexplained Includes clinically significant unexplained physical physical symptoms, obsessions, compulsions, symptoms, obsessions, compulsions, or intrusive or intrusive recollections of traumarecollections of trauma

Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006

AnxietyAnxiety

Anxiety =Anxiety =Likelihood x Harm

Ability to cope

Overestimated

Underestimated

Beck et al. 1985

Pathophysiology of Pathophysiology of AnxietyAnxiety

Caudate nucleus has been implicated Caudate nucleus has been implicated in OCDin OCD

fMRI studies have found increased fMRI studies have found increased activity in the amygdala in PTSDactivity in the amygdala in PTSD

Abnormalities in parahippocampal Abnormalities in parahippocampal gyrus in Panic Disordergyrus in Panic Disorder

3 major neurotransmitters involved 3 major neurotransmitters involved are norepinephrine, serotonin, and are norepinephrine, serotonin, and GABAGABA

Kaplan and Sadock’s Synopsis of Psychiatry 10th edition

Limbic cortex

Periaqueductal Gray matter

Brain Stem

Ventral Tegmental Area

Hippocampus

Amygdala

Nucleus accumbens

Orbitofrontal cortex

* Slide courtesy of Dr. Elliott Lee

Locus coeruleus

AnxietyAnxiety Patients try to alleviate Patients try to alleviate

the unpleasant feeling the unpleasant feeling of anxiety by:of anxiety by:

1)1) Avoiding the triggerAvoiding the trigger2)2) Developing a safety Developing a safety

behaviour (i.e. having behaviour (i.e. having someone else someone else accompany them)accompany them)

3)3) Using a substance or Using a substance or medicationmedication

Anxiety Disorders in Anxiety Disorders in DSM-IV TRDSM-IV TR

Panic Disorder with and without agoraphobiaPanic Disorder with and without agoraphobiaAgoraphobia without history of Panic DisorderAgoraphobia without history of Panic DisorderSocial PhobiaSocial PhobiaSpecific PhobiaSpecific PhobiaObsessive Compulsive DisorderObsessive Compulsive DisorderGeneralized Anxiety DisorderGeneralized Anxiety DisorderPost Traumatic Stress DisorderPost Traumatic Stress DisorderAcute Stress DisorderAcute Stress DisorderAnxiety Disorder due to a General Medical ConditionAnxiety Disorder due to a General Medical ConditionSubstance-Induced Anxiety DisorderSubstance-Induced Anxiety DisorderAnxiety Disorder NOSAnxiety Disorder NOS

EpidemiologyEpidemiology

Lifetime prevalence for any anxiety Lifetime prevalence for any anxiety disorder ranges from 10% to 29%disorder ranges from 10% to 29%

12 month prevalence 18%12 month prevalence 18% Common presentation in primary care Common presentation in primary care 1:5 to 1:12 patients presenting to 1:5 to 1:12 patients presenting to

primary care will have an anxiety primary care will have an anxiety disorderdisorder

Suicide rate 10 x higher than general Suicide rate 10 x higher than general populationpopulation


Initial Assessment of Initial Assessment of Patients with AnxietyPatients with Anxiety

Four scenarios:Four scenarios: 1) Anxiety disorder is primary and there 1) Anxiety disorder is primary and there

is no physical disorder present (any is no physical disorder present (any physical symptoms present are due to the physical symptoms present are due to the anxiety)anxiety)

2) The anxiety is secondary to a physical 2) The anxiety is secondary to a physical illness (e.g. hyperthyroidism)illness (e.g. hyperthyroidism)

3) The anxiety is secondary to a 3) The anxiety is secondary to a medication or substancemedication or substance

4) Both an anxiety and physical disorder 4) Both an anxiety and physical disorder are present by not causally relatedare present by not causally related


Medical conditions that Medical conditions that mimic or worsen anxiety mimic or worsen anxiety

symptomssymptomsEndocrine Endocrine conditionsconditions

HyperthyroidismHyperthyroidism

HypothyroidismHypothyroidism

PheochromocytomaPheochromocytoma

Cushing’s diseaseCushing’s disease

Addison’s diseaseAddison’s disease

MenopauseMenopause

CardiovascularCardiovascular Acute Coronary SyndromeAcute Coronary Syndrome

ArrhythmiaArrhythmia

CHFCHF

HypertensionHypertension

HypertensionHypertension

Mitral Valve ProlapseMitral Valve Prolapse

Medical conditions that Medical conditions that mimic or worsen anxiety mimic or worsen anxiety

symptoms (con’t)symptoms (con’t)NeurologicalNeurological EpilepsyEpilepsy

Cerebrovascular diseaseCerebrovascular disease

Meniere’s diseaseMeniere’s disease

Multiple SclerosisMultiple Sclerosis

MigraineMigraine

EncephalitisEncephalitis

Early dementiaEarly dementia

MetabolicMetabolic PorphyriaPorphyria

DiabetesDiabetes

PulmonaryPulmonary AsthmaAsthma

COPDCOPD

Pulmonary EmbolismPulmonary Embolism

PneumoniaPneumonia

Medical conditions that mimic Medical conditions that mimic or worsen anxiety symptoms or worsen anxiety symptoms

(con’t)(con’t)OtherOther AnemiaAnemia

UTI (in elderly)UTI (in elderly)

Irritable Bowel SyndromeIrritable Bowel Syndrome

Heavy metal poisoningHeavy metal poisoning

B12 deficiencyB12 deficiency

Electrolyte disturbancesElectrolyte disturbances

MedicationsMedications Anti-cholinergicsAnti-cholinergics

SteroidsSteroids

Stimulants (methylphenidate Stimulants (methylphenidate and amphetamine based)and amphetamine based)

TheophyllineTheophylline

VentolinVentolin

Nasal decongestantsNasal decongestants

SSRIsSSRIs

Substance Abuse and Substance Abuse and AnxietyAnxiety

Substance abuse is often co-morbid with Substance abuse is often co-morbid with anxiety disorders as patients often try to self-anxiety disorders as patients often try to self-medicate to cope with anxiety medicate to cope with anxiety

37% of patients with GAD and 20-40% of 37% of patients with GAD and 20-40% of patients with Panic Disorder have alcohol patients with Panic Disorder have alcohol abuse/dependenceabuse/dependence

Drug intoxication can mimic anxiety:Drug intoxication can mimic anxiety: - - Amphetamines - MarijuanaAmphetamines - Marijuana

- Caffeine - Hallucinogens- Caffeine - Hallucinogens

- Nicotine - Ecstasy- Nicotine - Ecstasy

- Cocaine - Excessive alcohol consumption- Cocaine - Excessive alcohol consumption

- Phencyclidine- Phencyclidine

Substance Abuse and Substance Abuse and Anxiety (con’t)Anxiety (con’t)

Drug withdrawal also associated Drug withdrawal also associated with anxietywith anxiety

AlcoholAlcohol BenzodiazepinesBenzodiazepines OpiateOpiate BarbiturateBarbiturate Anti-hypertensivesAnti-hypertensives

Key features Key features Panic Panic

DisorderDisorder• Fear of losing control, dying or Fear of losing control, dying or going crazygoing crazy• Avoid situations in which attacks Avoid situations in which attacks may occurmay occur

AgoraphoAgoraphobiabia

• Fear of situations from which Fear of situations from which escape may be difficult or help escape may be difficult or help unavailable (crowds, bus, bridge unavailable (crowds, bus, bridge etc.)etc.)

OCDOCD • Intrusive, unwanted thoughts or Intrusive, unwanted thoughts or urges (urges (obsessionsobsessions) and/or ) and/or repetitive behaviours or mental repetitive behaviours or mental acts (acts (compulsionscompulsions))• Fear of harm, uncertainty, Fear of harm, uncertainty, uncontrollable actionsuncontrollable actions

Key features Key features GeneraliGenerali

zedzed

Anxiety Anxiety

• Anxiety regarding a number of Anxiety regarding a number of everyday eventseveryday events• Future and uncertainty difficult to Future and uncertainty difficult to acceptaccept

Social Social AnxietyAnxiety

• Fear of humiliation, Fear of humiliation, embarrassment or scrutiny by embarrassment or scrutiny by othersothers

PTSDPTSD • Re-experiencing of trauma Re-experiencing of trauma through flashbacks, dreams, through flashbacks, dreams, recollectionsrecollections

Specific Specific phobiaphobia

• Fear of a specific object, animal or Fear of a specific object, animal or situationsituation

Generalized Anxiety Generalized Anxiety Disorder – DSM IV TRDisorder – DSM IV TR

Excessive anxiety and worry about a Excessive anxiety and worry about a number of events or activitiesnumber of events or activities, occurring , occurring more days than not for at least more days than not for at least 6 months6 months

Difficult to Difficult to controlcontrol the worry the worry Associated with Associated with three three of the followingof the following

Restlessness, difficulty concentrating, muscle tension, Restlessness, difficulty concentrating, muscle tension, fatigue, sleep disturbances, irritabilityfatigue, sleep disturbances, irritability

Not due to a substance, medical condition Not due to a substance, medical condition or other mental disorderor other mental disorder

Causes clinically significant distress or Causes clinically significant distress or impairment in functioningimpairment in functioning

Generalized Anxiety Generalized Anxiety Disorder Disorder

Lifetime prevalence 6%Lifetime prevalence 6%11

68 % comorbidity with other psychiatric 68 % comorbidity with other psychiatric illness (depression, substance abuse, illness (depression, substance abuse, other anxiety disorder)other anxiety disorder)

Female to male ratio 2:1Female to male ratio 2:111

25% of 125% of 1stst degree relatives also have degree relatives also have GADGAD22

Twin studies show concordance rate of Twin studies show concordance rate of 50%50%22

2Kaplan and Sadock’s Synopsis of Psychiatry 10th edition

1Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006

Generalized Anxiety Generalized Anxiety DisorderDisorder

Chronic condition, usually lifelongChronic condition, usually lifelong Screening questionsScreening questions

Do others call you a worry-wort?Do others call you a worry-wort? What kinds of things do you worry about?What kinds of things do you worry about?

Usually seek treatment for somatic Usually seek treatment for somatic symptoms rather than anxietysymptoms rather than anxiety

Only 1/3 seek psychiatric treatmentOnly 1/3 seek psychiatric treatment Often see specialists (GI, cardiology, Often see specialists (GI, cardiology,

internists)internists)Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006

GAD - treatmentGAD - treatment Pharmacotherapy:Pharmacotherapy:

11stst line SSRI or SNRI line SSRI or SNRI 22ndnd line Benzodiazepine line Benzodiazepine

Only recommended for short term use Only recommended for short term use due to side effects (cognitive due to side effects (cognitive impairment, ataxia, sedation) and impairment, ataxia, sedation) and dependence and withdrawal)dependence and withdrawal)

Avoid in substance abuse and the Avoid in substance abuse and the elderlyelderly

33rdrd line Adjunctive olanzapine or risperidone line Adjunctive olanzapine or risperidone MirtazapineMirtazapine


GAD - treatmentGAD - treatment

An optimal trial involves 8-12 weeksAn optimal trial involves 8-12 weeks If there is not an adequate response, If there is not an adequate response,

switch to another 1switch to another 1stst line agent line agent Reasonable to try another 1Reasonable to try another 1stst line line

agent with a different mechanism of agent with a different mechanism of actionaction

Treatment resistant patients should Treatment resistant patients should be assessed for comorbid medical and be assessed for comorbid medical and psychiatric conditionspsychiatric conditionsCan J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006

GAD - treatmentGAD - treatment Psychological treatment:Psychological treatment: CBT as effective as medication (also 1CBT as effective as medication (also 1stst

line)line) CBT involves:CBT involves:

PsychoeducationPsychoeducation Cognitive interventions (addressing cognitive Cognitive interventions (addressing cognitive

distortions, unrealistic beliefs)distortions, unrealistic beliefs) ExposureExposure Relaxation strategiesRelaxation strategies Problem SolvingProblem Solving Assertiveness trainingAssertiveness training Relapse PreventionRelapse Prevention

Panic Attack – DSM-IV Panic Attack – DSM-IV criteriacriteria

A discrete period of intense fear or discomfort, in A discrete period of intense fear or discomfort, in which 4 or more develop abruptly and reach a peak which 4 or more develop abruptly and reach a peak within ten minutes:within ten minutes:

Palpitations, increased heart ratePalpitations, increased heart rate SweatingSweating Tremor or shakingTremor or shaking Shortness of breath or smothering sensationShortness of breath or smothering sensation Feeling of chokingFeeling of choking Chest painChest pain Nausea or abdominal distressNausea or abdominal distress Feeling dizzy, lightheaded, or faintFeeling dizzy, lightheaded, or faint DerealizationDerealization DepersonalizationDepersonalization ParasthesiasParasthesias Chills or hot flushesChills or hot flushes Fear of losing control or going crazyFear of losing control or going crazy Fear of dyingFear of dying

Panic Disorder with or Panic Disorder with or without agoraphobia – without agoraphobia –

DSM-IV criteriaDSM-IV criteria The person has experienced both :The person has experienced both :

Recurrent, unexpected panic attacksRecurrent, unexpected panic attacks One or more of the attacks has been followed by One or more of the attacks has been followed by

either either

1) Persistent concern about having another 1) Persistent concern about having another attackattack

2) Worry about the implications of the attack2) Worry about the implications of the attack

3) Significant change in behaviour3) Significant change in behaviour

The presence (or absence of agoraphobia)The presence (or absence of agoraphobia) Not due to a substance, medication or Not due to a substance, medication or

medical conditionmedical condition Not better accounted for by another mental Not better accounted for by another mental

disorderdisorder

Panic DisorderPanic Disorder

Lifetime prevalence of Panic Disorder is Lifetime prevalence of Panic Disorder is 4.7%4.7%

Lifetime prevalence of having a panic Lifetime prevalence of having a panic attack is 15%attack is 15%

1/3 to 1/2 of patients also have 1/3 to 1/2 of patients also have agoraphobiaagoraphobia

More common in women than in menMore common in women than in men Generally begins in late adolescence or Generally begins in late adolescence or

early adulthoodearly adulthoodCan J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006

Panic DisorderPanic Disorder

20 X the risk of suicidal ideation and suicide 20 X the risk of suicidal ideation and suicide attempts as the general populationattempts as the general population

Felt to be related to dysregulation of brain Felt to be related to dysregulation of brain noradrenergic systems noradrenergic systems

Abnormalities have been found in the Abnormalities have been found in the autonomic nervous system of some patients autonomic nervous system of some patients (increased sympathetic tone, less adaptive (increased sympathetic tone, less adaptive to repeated stimulit)to repeated stimulit)

Kaplan and Sadock’s Synopsis of Psychiatry 10th edition

Panic DisorderPanic Disorder Initially, panic attacks are unexpectedInitially, panic attacks are unexpected

Can occur any time (even night) Can occur any time (even night)

Can also develop panic attacks that have Can also develop panic attacks that have triggers (situationally-predisposed panic triggers (situationally-predisposed panic attacks)attacks)

Patients begin to have anticipatory anxiety Patients begin to have anticipatory anxiety about having another panic attackabout having another panic attack

This can lead to avoidance of situations where This can lead to avoidance of situations where escape or help may not be readily available escape or help may not be readily available (agoraphobia)(agoraphobia)

Panic Disorder - Panic Disorder - TreatmentTreatment

Pharmacotherapy:Pharmacotherapy: 11stst line SSRI or SNRI line SSRI or SNRI 22ndnd line Benzodiazepines line Benzodiazepines

Only recommended for short term use due Only recommended for short term use due to side effects (cognitive impairment, to side effects (cognitive impairment, ataxia, sedation) and dependence and ataxia, sedation) and dependence and withdrawalwithdrawal

Avoid in substance abuse and the elderlyAvoid in substance abuse and the elderly

** Often clinically, a small dose of long acting ** Often clinically, a small dose of long acting benzodiazepine is started along with SSRI/SNRI to benzodiazepine is started along with SSRI/SNRI to provide more immediate relief from distressing provide more immediate relief from distressing symptomssymptoms

i.e. 0.5 mg clonazepam BID for 2-3 weeks, then tapered i.e. 0.5 mg clonazepam BID for 2-3 weeks, then tapered until it is stoppeduntil it is stopped


Panic Disorder - Panic Disorder - TreatmentTreatment

Psychological treatment:Psychological treatment:

CBT most consistently efficacious psychotherapy CBT most consistently efficacious psychotherapy for Panic Disorder, according to the literaturefor Panic Disorder, according to the literature

Individual or group therapy, bibliotherapyIndividual or group therapy, bibliotherapy CBT for Panic Disorder includes same CBT CBT for Panic Disorder includes same CBT

concepts of psychoeducation, cognitive concepts of psychoeducation, cognitive approaches, relaxation, problem solving approaches, relaxation, problem solving

Also incorporates Also incorporates interoceptive exposureinteroceptive exposure (exposure to feared symptoms (exposure to feared symptoms therapist may ask therapist may ask patient to hyperventilate or spin to make patient to hyperventilate or spin to make themselves dizzy)themselves dizzy)

Exposure to avoided situations is importantExposure to avoided situations is important

Obsessive Compulsive Obsessive Compulsive Disorder – DSM IV criteriaDisorder – DSM IV criteria

Either obsessions or compulsionsEither obsessions or compulsions ObsessionsObsessions are defined as: are defined as:

Recurrent and persistent thoughts, images or impulses Recurrent and persistent thoughts, images or impulses that are experienced as intrusive and inappropriate that are experienced as intrusive and inappropriate and cause marked anxiety/distressand cause marked anxiety/distress

Not simply excessive worries about real-life problemsNot simply excessive worries about real-life problems Person attempts to ignore or suppress the obsessions, Person attempts to ignore or suppress the obsessions,

or neutralize them with other thoughts or actionsor neutralize them with other thoughts or actions Recognized as a product of the patient’s own mindRecognized as a product of the patient’s own mind

CompulsionsCompulsions are defined as: are defined as: Repetitive behaviours or mental acts that the person Repetitive behaviours or mental acts that the person

feels driven to perform in response to an obsession, or feels driven to perform in response to an obsession, or according to rigid rulesaccording to rigid rules

Compulsions are aimed at reducing distress or Compulsions are aimed at reducing distress or preventing some dreaded event, however they are not preventing some dreaded event, however they are not connected in a realistic way to what they are meant to connected in a realistic way to what they are meant to neutralize, or are clearly excessiveneutralize, or are clearly excessive

Obsessive Compulsive Obsessive Compulsive Disorder – DSM IV criteria Disorder – DSM IV criteria

(con’t)(con’t) At some point during the course of the disorder, At some point during the course of the disorder,

the the person recognizesperson recognizes that the obsessions that the obsessions and/or compulsions are and/or compulsions are excessive or excessive or unreasonableunreasonable

The obsessions and/or compulsions cause The obsessions and/or compulsions cause marked distressmarked distress, , are time consuming (> 1 are time consuming (> 1 h/dayh/day), or significantly ), or significantly interfere with interfere with functioningfunctioning

Not due to substance, or another medical or Not due to substance, or another medical or mental disordermental disorder

Obsessive-Compulsive Obsessive-Compulsive DisorderDisorder

Estimated lifetime prevalence of 1.6%Estimated lifetime prevalence of 1.6% Median age of onset 19 years (range 14 – Median age of onset 19 years (range 14 –

30 years)30 years) 60% are female60% are female High psychiatric co-morbidity rate (56% -High psychiatric co-morbidity rate (56% -

83%)83%) Common co-morbidities include Common co-morbidities include substance substance

abuseabuse, , depression, social phobiadepression, social phobia, , generalized anxiety disorder, panic disordergeneralized anxiety disorder, panic disorder



In 50-70% of patients, onset of In 50-70% of patients, onset of symptoms is following a stressful event symptoms is following a stressful event (i.e. pregnancy, death)(i.e. pregnancy, death)

Course is usually long, can be constant Course is usually long, can be constant or fluctuatingor fluctuating

20-30 % have significant improvement20-30 % have significant improvement 40-50% have moderate improvement40-50% have moderate improvement 20-30% have no improvement or 20-30% have no improvement or

worseningworseningKaplan and Sadock’s Synopsis of Psychiatry 10th edition


20-30% have tics, 6-7% Tourette’s20-30% have tics, 6-7% Tourette’s

Possible link between a subset of OCD and ticsPossible link between a subset of OCD and tics

PET studies have shown increased activity in the PET studies have shown increased activity in the frontal lobes, basal ganglia (caudate), and cingulum frontal lobes, basal ganglia (caudate), and cingulum in patients with OCDin patients with OCD

PANDAS – Pediatric Autoimmune Neuropsychiatric PANDAS – Pediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal infectionsDisorders associated with Streptococcal infections

Streptococcus infection may trigger an autoimmune Streptococcus infection may trigger an autoimmune response which causes acute onset OCD symptoms response which causes acute onset OCD symptoms and tics in childrenand tics in childrenKaplan and Sadock’s Synopsis of Psychiatry 10th edition

Obsessive-Compulsive Obsessive-Compulsive DisorderDisorder Most common obsessions include:Most common obsessions include:

Contamination (#1)Contamination (#1) Doubt/safety (idea that stove was left on, door unlocked Doubt/safety (idea that stove was left on, door unlocked

etc.) (#2)etc.) (#2) Sexual and aggressive impulses (#3)Sexual and aggressive impulses (#3) Symmetry and exactness (#4)Symmetry and exactness (#4) Somatic and religious preoccupationsSomatic and religious preoccupations

Most common compulsions include:Most common compulsions include: CheckingChecking WashingWashing RepeatingRepeating OrderingOrdering CountingCounting HoardingHoarding

OCD - treatmentOCD - treatment Pharmacotherapy:Pharmacotherapy:

11stst line SSRI (serotonergic response needed) line SSRI (serotonergic response needed) 22ndnd line : Clomipramine (2 line : Clomipramine (2ndnd line due to side line due to side

effects – cardiotoxicity, anticholinergic, drug effects – cardiotoxicity, anticholinergic, drug interactions and lethality in overdose)interactions and lethality in overdose)

Effexor XR, MirtazapineEffexor XR, Mirtazapine Adjunctive RisperidoneAdjunctive Risperidone

Dosages of meds e.g. SSRIs may need to be Dosages of meds e.g. SSRIs may need to be higher than in mood disordershigher than in mood disorders

Response may take 6 wks or longer Response may take 6 wks or longer (Guidelines state adequate trial 6-8 weeks)(Guidelines state adequate trial 6-8 weeks)


OCD - treatmentOCD - treatment Psychological Psychological

1) Exposure with Response Prevention 1) Exposure with Response Prevention (ERP) – form of behavioural therapy(ERP) – form of behavioural therapy

2) CBT which combines Exposure and Response 2) CBT which combines Exposure and Response Prevention with cognitive interventionsPrevention with cognitive interventions

Posttraumatic Stress Posttraumatic Stress Disorder DSM-IV criteriaDisorder DSM-IV criteria

The person has been exposed to a traumatic The person has been exposed to a traumatic event which included both:event which included both: 1) The person experienced or witnessed an event 1) The person experienced or witnessed an event

involving actual or threatened death or serious involving actual or threatened death or serious injury, or a threat to personal integrity of self or injury, or a threat to personal integrity of self or othersothers

2) Response was fear, horror, or helplessness2) Response was fear, horror, or helplessness

The traumatic event is re-experienced The traumatic event is re-experienced including at least one of:including at least one of: Distressing memories, dreams, acting or feeling Distressing memories, dreams, acting or feeling

as if event is recurring (illusions, dissociative as if event is recurring (illusions, dissociative flashbacks, hallucinations), intense psychological flashbacks, hallucinations), intense psychological or physiological distress when exposed to cues or physiological distress when exposed to cues that symbolize the traumathat symbolize the trauma


Persistent avoiding of stimuli associated with Persistent avoiding of stimuli associated with the trauma and numbing of responsiveness the trauma and numbing of responsiveness including at least 3 of:including at least 3 of: Efforts to avoid thoughts, feelings, conversations Efforts to avoid thoughts, feelings, conversations

associated with the traumaassociated with the trauma Efforts to avoid people, places and activities Efforts to avoid people, places and activities

associated with the traumaassociated with the trauma Inability to recall an important aspect of the Inability to recall an important aspect of the

traumatrauma Feeling of detachment or estrangement from Feeling of detachment or estrangement from

othersothers Restricted range of affectRestricted range of affect Sense of foreshortened futureSense of foreshortened future


Persistent symptoms of increased arousal Persistent symptoms of increased arousal including at least two of:including at least two of: Difficulty falling or staying asleepDifficulty falling or staying asleep Irritability or outbursts of angerIrritability or outbursts of anger Difficulty concentratingDifficulty concentrating HypervigilanceHypervigilance Exaggerated startle reflexExaggerated startle reflex

Duration is more than 1 monthDuration is more than 1 month

Causes clinically significant distress or Causes clinically significant distress or impairment in functioningimpairment in functioning

Posttraumatic Stress Posttraumatic Stress DisorderDisorder

Key features include exposure to trauma, re-Key features include exposure to trauma, re-experiencing of the trauma, avoidance and experiencing of the trauma, avoidance and emotional numbing, and hyperarousalemotional numbing, and hyperarousal

Examples of traumas include exposure to war, Examples of traumas include exposure to war, terrorist attacks, natural disasters, accidents terrorist attacks, natural disasters, accidents involving serious injury or death, rape, tortureinvolving serious injury or death, rape, torture

If symptoms are present for less than one If symptoms are present for less than one month, then the diagnosis may be Acute month, then the diagnosis may be Acute Stress DisorderStress Disorder


Prevalence in Canada 2.4% (1 month Prevalence in Canada 2.4% (1 month prevalence) and 9.2% (lifetime prevalence) and 9.2% (lifetime prevalence)prevalence)

Higher among women than menHigher among women than men Lifetime prevalence estimates 16-37% in Lifetime prevalence estimates 16-37% in

areas of the world where conflict has areas of the world where conflict has occurredoccurred

Frequent co-morbidity with depression, Frequent co-morbidity with depression, substance abuse, other anxiety disorderssubstance abuse, other anxiety disorders



6X increased risk of suicide attempts6X increased risk of suicide attempts Predisposing factors include:Predisposing factors include:

Childhood traumaChildhood trauma Inadequate support systemInadequate support system FemaleFemale Genetic vulnerability to psychiatric Genetic vulnerability to psychiatric

illnessillness Excessive alcohol use (recent)Excessive alcohol use (recent)

Posttraumatic Stress Posttraumatic Stress Disorder - TreatmentDisorder - Treatment

Guidelines recommend SSRI/SNRI Guidelines recommend SSRI/SNRI as first line treatmentas first line treatment11

Recommended that patients with Recommended that patients with PTSD should continue medication PTSD should continue medication for at least 1 yearfor at least 1 year11

In practice, agents to help with In practice, agents to help with insomnia are often added (i.e. insomnia are often added (i.e. Trazadone)Trazadone)

1Can J Psychiatry Clinical Practice Guidelines for the Management of Anxiety Disorders July 2006

Posttraumatic Stress Posttraumatic Stress Disorder - TreatmentDisorder - Treatment

Other meds sometimes used include:Other meds sometimes used include: Clonidine (antiadrenergic agent)Clonidine (antiadrenergic agent) Prazosin for nightmares (alpha-1 Prazosin for nightmares (alpha-1

adrenergic antagonist)adrenergic antagonist)

Psychological treatment:Psychological treatment: CBT recommendedCBT recommended

Social Anxiety Disorder Social Anxiety Disorder (Social phobia) – DSM IV (Social phobia) – DSM IV

criteriacriteria Marked and persistent fear of social or Marked and persistent fear of social or

performance situations in which the person is performance situations in which the person is exposed to unfamiliar people or possible exposed to unfamiliar people or possible scrutiny by othersscrutiny by others Fear that they will embarrass or humiliate themselvesFear that they will embarrass or humiliate themselves

Exposure to the feared situation invariable Exposure to the feared situation invariable produces anxiety which may be in the form of a produces anxiety which may be in the form of a panic attackpanic attack

The person recognizes that the fear is excessive The person recognizes that the fear is excessive or unreasonableor unreasonable

Social Anxiety Disorder Social Anxiety Disorder (Social phobia) – DSM IV (Social phobia) – DSM IV

criteria (con’t)criteria (con’t) The feared situations are avoided or endured The feared situations are avoided or endured

with intense anxiety and distresswith intense anxiety and distress The avoidance, anxious anticipation or distress The avoidance, anxious anticipation or distress

interferes with functioning or causes marked interferes with functioning or causes marked distressdistress

In individuals under 18, duration is at least 6 In individuals under 18, duration is at least 6 monthsmonths

Not due to substance, medical condition or Not due to substance, medical condition or other mental disorderother mental disorder

If a medical condition is present, the fear is not If a medical condition is present, the fear is not related to it (i.e. trembling in Parkinson’s)related to it (i.e. trembling in Parkinson’s)

Social PhobiaSocial Phobia Most people in the general population Most people in the general population

experience a degree of discomfort with experience a degree of discomfort with certain social situationscertain social situations

Generalized type vs. non-generalizedGeneralized type vs. non-generalized (a (a restricted number of situations i.e. public restricted number of situations i.e. public speaking)speaking)

Differentiate fromDifferentiate from panic disorderpanic disorder (panic (panic attacks in social phobia always occur in feared attacks in social phobia always occur in feared situations)situations)

Differentiate from normal shynessDifferentiate from normal shyness (shyness (shyness should not cause functional impairment or marked should not cause functional impairment or marked distress)distress)

Social PhobiaSocial Phobia

Has significant impact on quality of lifeHas significant impact on quality of life

Lifetime prevalence of 8-12Lifetime prevalence of 8-12% 1 % 1 (one of (one of the most common anxiety disorders)the most common anxiety disorders)

Early onset, usually in childhood Early onset, usually in childhood

Chronic course, usually 20 years or Chronic course, usually 20 years or longerlonger

r


Social PhobiaSocial Phobia Interferes with career, relationship, goals Interferes with career, relationship, goals ““illness of missed opportunities”illness of missed opportunities” Comorbid conditions include substance Comorbid conditions include substance

abuse, depression, or another anxiety abuse, depression, or another anxiety disorderdisorder

Key symptoms include blushing, Key symptoms include blushing, sweating, palpitations, tremor and sweating, palpitations, tremor and lightheadedness, panic attackslightheadedness, panic attacks

Situations are often avoided as an effort Situations are often avoided as an effort to alleviate distressto alleviate distress

Social Phobia - treatmentSocial Phobia - treatment Pharmacotherapy:Pharmacotherapy:

11stst line SSRI or SNRI line SSRI or SNRI 22ndnd line Benzodiazepine line Benzodiazepine

Only recommended for short term use Only recommended for short term use due to side effects (cognitive due to side effects (cognitive impairment, ataxia, sedation) and impairment, ataxia, sedation) and dependence and withdrawaldependence and withdrawal

Avoid in people with substance abuse Avoid in people with substance abuse and the elderlyand the elderly

33rdrd line Adjunctive Abilify or Risperidone line Adjunctive Abilify or Risperidone Mirtazapine, wellbutrinMirtazapine, wellbutrin

** Although not in guidelines, in practice, ** Although not in guidelines, in practice, beta blockers have been used with effect for beta blockers have been used with effect for non-generalized type performance anxietynon-generalized type performance anxiety


Social Phobia - treatmentSocial Phobia - treatment

Psychological treatmentPsychological treatment CBT (group or individual)CBT (group or individual) CBT for social phobia includes exposure CBT for social phobia includes exposure

to feared situations and social skills to feared situations and social skills trainingtraining

Similar efficacy to pharmacotherapySimilar efficacy to pharmacotherapy In practice, CBT and medications are In practice, CBT and medications are

often combined often combined After discontinuation of CBT or After discontinuation of CBT or

medications, gains with CBT last longermedications, gains with CBT last longer

Specific Phobia – DSM IV Specific Phobia – DSM IV criteriacriteria

Excessive or unreasonable fear cued by the Excessive or unreasonable fear cued by the presence or anticipation of a specific object or presence or anticipation of a specific object or situation (insects, flying, heights, blood)situation (insects, flying, heights, blood)

Exposure provokes an immediate anxiety Exposure provokes an immediate anxiety responseresponse

Fear is recognized as excessive or unreasonableFear is recognized as excessive or unreasonable Situation is avoided or endured with intense Situation is avoided or endured with intense

distressdistress Marked distress or interferes with functioningMarked distress or interferes with functioning Not due to a substance, medical condition or Not due to a substance, medical condition or

other mental disorderother mental disorder

Specific PhobiaSpecific Phobia

Lifetime prevalence of 12%Lifetime prevalence of 12% Most common mental disorder Most common mental disorder Begins at young age, 5-12 years oldBegins at young age, 5-12 years old Treatment is exposure based therapyTreatment is exposure based therapy Graded exposure helpfulGraded exposure helpful Virtual reality or computer programs Virtual reality or computer programs

sometimes used for fear of heights, sometimes used for fear of heights, flying, dentistflying, dentist


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Anxiety Disorders Back to Basics 2012 Dr. Holly Dornan PGY-4 Psychiatry Resident University of...

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